PERIOPERATIVE NURSING

WHAT IS SURGERY? 1. Emergency Surgery

Treatment of disease, injury, etc. by manual and operative means. 2. Elective Surgery
(Webster, 1978) Degree of Risk
The three phases of surgery are together referred to as 1. Major Surgery
perioperative period. 2. Minor Surgery

THREE PHASES OF SURGERY DEGREE OF RISK INVOLVED IN A SURGICAL PROCEDURE IS

1. Preoperative Phase begins when the decision to have surgery is AFFECTED BY THE FOLLOWING FACTORS:
made and ends when the client is transferred to the operating table. 1. Age
2. Intraoperative Phase begins when the client is transferred to the 2. General Health
operating table and ends when the client is admitted to the 3. Medications
postanesthesia care unit (PACU) or recovery room (RR) Anticoagulants
3. Postoperative Phase begins with the admission of the client to the Tranquilizers
postanesthesia area and ends when the healing is complete. Corticosteroids
Diuretics
TYPES OF SURGERY 4. Mental Status
According to Purpose:
1. Diagnostic confirms or establishes a diagnosis HEALTH PROBLEMS THAT INCREASE SURGICAL RISK
2. Palliative relieves or reduces pain and symptoms 1. Malnutrition
of a disease 2. Obesity
3. Ablative removes a diseased body part 3. Cardiac Conditions
4. Constructive restores function or appearance that 4. Blood Coagulation Disorders
has been lost or reduced 5. Upper Respiratory Tract Infections
5. Transplant replaces malfunctioning structures 6. Renal Disease or Insufficiency
7. Diabetes Mellitus
8. Liver Disease
Degree of Urgency 9. Uncontrolled Neurological Disease

PREOPERATIVE PHASE

Preoperative Consent/Informed Consent protects patients from having Anticipatory Grieving

any surgical procedure they do not want or understand. It also protects Ineffective Individual Coping
that hospital and health personnel from claims made by patients and
families later on that permission was not obtained. PREOPERATIVE PHASE: PLANNING
Overall goal is to ensure that the client is mentally and physically
PREOPERATIVE INSTRUCTIONS: Preoperative Regimen prepared for surgery
Explain the need for preoperative tests (eg. Laboratory, x-ray, ECG, Planning for home care begins in preoperative phase
ETC). Planning Guides:
Discuss bowel preparations, if required. 1. Surgical Preparation
Discuss skin preparation including operative area and preoperative 2. Teaching Procedures/Treatment
bath or shower. 3. Anxiety Reduction
Discuss preoperative medications, if ordered. 4. Coping Enhancement
Explain individual therapies ordered by the physician, such as 5. Family Support
intravenous therapy, the insertion of a urinary catheter or 6. Decision-Making Support
nasogastric tube, use of spirometer, or antiemboli stockings.
Discuss the visit by the anesthetist/anesthesiologist PREOPERATIVE PHASE: IMPLEMENTING
Explain the need to restrict food and oral fluids at least 8 hours Preoperative Teaching
before surgery. Physical Preparation
Provide a general timetable for perioperative events, including time 1. Nutrition and Fluids
of surgery. 2. Elimination
3. Hygiene
PREOPERATIVE INSTRUCTIONS: Postoperative Regimen 4. Medication
Discuss the postanesthesia recovery rooms routines and 5. Rest and Sleep
emergency equipment. 6. Valuables
Review type and frequency of assessment activities 7. Prostheses
Discuss pain management 8. Skin Preparation
Explain usual activity restrictions and precautions related to getting 9. Vital Signs
up for the first time postoperatively 10. Special Orders
Describe usual dietary alterations 11. Antiemboli Stockings
Discuss postoperative dressing and drains
Provide an explanation and tour of intensive care unit if client is to PREOPERATIVE PHASE: EVALUATING
be transferred there postoperatively. Goals established during the planning stage are evaluated
Discuss the need to remove jewelry, make-up, and all prostheses according to specific desired outcomes
(eg. Dentures (complete & partial), eyeglasses, hearing aid, wig,
etc.) Day Surgery Clients
Inform client about the preoperative holding area, and give the Confirm place and time of surgery, including when to arrive (eg. 1 to
location of the waiting room for support people (relatives) 1 hours before scheduled surgery) and where to register (eg.
Teach deep-breathing and coughing exercises, leg exercises, ways Reception desk)
to turn and move (see handout) Discuss what to wear (eg. Clients having hand surgery should wear
Complete the preoperative checklist. a garment with large sleeve openings to fit over a bulky dressing; all
clients need to leave valuables at home.)
PREOPERATIVE PHASE: ASSESSING Explain the need for a responsible adult to drive or accompany the
Nursing History client home, and arrange a place for them to meet.
Physical Assessment Discuss the medications including specific preoperative medications
Screening Tests/Laboratory Examinations and the clients current medication regimen.
Review with the client any tests ordered and the need for a urine
PREOPERATIVE PHASE: DIAGNOSING specimen the morning of surgery.
Knowledge Deficit Communicate by telephone the evening before surgery to confirm
Fear time of surgery and arrival time, and call again the evening after
Sleep Pattern Disturbance surgery to assess progress.

INTRAOPERATIVE PHASE

ANESTHESIA TYPES OF ANESTHESIA

Impairs the clients ability to respond to environmental stimuli General Anesthesia there is loss of all sensation and
Patients are unable to help themselves because of some degree of consciousness.
changes in consciousness although this may vary from patient to Regional Anethesia is the temporary interruption of the
patient. transmission of nerve impulses to and from a specific area or region
of the body.
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 1. Topical (surface) Anesthesia applied directly to the skin and
mucous membranes, open skin surfaces, wounds, and burns.
(eg. Lidocaine and benzocaine)
2. Local Anesthesia (infiltration) is injected into a specific area
and used for minor surgical procedures such as suturing a
small wound or performing a biopsy
3. Nerve Block anesthetic agent is injected into and around a
nerve or small nerve group that supplies sensation to a small
area of the body.
4. Intravenous Block (Bier Block) used most for most
procedures involving the arm, wrist and hand.
5. Spinal Anesthesia (subarachnoid block) requires a lumbar
puncture between L2 and S1. This could be low, medium, and
high spinals.
6. Epidural Anesthesia is the injection of an anesthetic agent
into the epidural space, the area inside the spinal column but
outside the dura mater.
Conscious sedation minimal depression of the level of
consciousness in which the client retains the ability to consciously
maintain a patent airway and respond appropriately to verbal and
physical stimuli.
INTRAOPERATIVE PHASE: ASSESSING
Nurse confirms patients identity
Assesses the clients physical and emotional status
Assessment continues throughout surgery (eg. Vital signs, I & O,
laboratory values, etc.) in order to rapidly identify adverse
responses to surgery or anesthesia.
INTRAOPERATIVE PHASE: DIAGNOSING
NANDA Nursing diagnoses that may be appropriate for the intraoperative
client include:
1. Risk for Aspiration
2. Altered Protection
3. Impaired Skin Integrity
4. Risk for Perioperative Positioning Injury
5. Risk for Altered Body Temperature
6. Altered Tissue Perfusion
7. Risk for Fluid Volume Deficit
INTRAOPERATIVE PHASE: PLANNING
The overall goals of care in the intraoperative period are to maintain the
clients safety and to maintain homeostasis. The following nursing
activities can be done to achieve these goals:
1. Position the client appropriately for surgery
2. Perform preoperative skin preparation
3. Assist in preparing and maintaining the sterile field
4. Open and dispense sterile supplies during surgery
5. Provide medications and solutions for the sterile field
6. Monitor and maintain a safe, aseptic environment
7. Manage catheters, tubes, drains, and specimens
8. Perform sponge, sharp, and instruments counts
9. Document nursing care provided and the clients response to
interventions.
INTRAOPERATIVE PHASE: IMPLEMENTING
Scrub Nurses assist the surgeons
Circulating Nurses assist the scrub nurses and the surgeon

POST OPERATIVE PHASE

POST OPERATIVE PHASE: ASSESSING

1. Surgeons post operative orders regarding: POST OPERATIVE PHASE: PLANNING
Food and fluids permitted by mouth Client goals during post operative period:
Intravenous solutions and intravenous medications Maintain comfort
Position in bed Promote healing
Medications ordered (eg. Analgesics, antibiotics, etc.) Prevent associated risks such as respiratory or cardiovascular
2. PACU Record: complications, infection, and other common problems
Operation performed associated with surgery.
Presence and location of drains Restore the highest possible level of wellness.
Anesthetic used Plan for home care.
Postoperative diagnosis
Estimated blood loss POST OPERATIVE PHASE: IMPLEMENTING
Medications administered in the PACU Nursing interventions designed tp promote client recover and prevent
3. Regular Assessment: complications include:
Level of consciousness Pain management
Vital signs Appropriate positioning
Skin color and temperature Incentive spirometry, deep-breathing and coughing exercises
Comfort Leg exercises
Fluid Balance Early ambulation
Dressing and bedclothes Adequate hydration
Drains and tubes Diet
Promoting urinary elimination
POST OPERATIVE PHASE: DIAGNOSING Suction maintenance
Actual and potential NANDA diagnoses: Wound care
Pain
Risk for infection Clients are usually discharged from PACU/RR when:
Risk for Fluid Volume Deficit 1. They are conscious and oriented.
Ineffective Airway Clearance 2. They are able to maintain a clear airway. Deep breathe and cough
Ineffective Breathing Pattern freely.
Self-care Deficit: Bathing Hygiene, Dressing/Grooming, 3. Vital signs have been stable or consistent with preoperative vital
Toileting signs for at least 30 minutes.
Altered Health Maintenance 4. Protective reflexes (eg. Gag, swallowing, cough, etc.) are active.
Body Image Disturbance 5. They are able to move four extremities.
6. Intake and urinary output is adequate (at least 30 ml./hr)
7. They are afebrile or a febrile condition had been attended to.
8. Dressings are dry and intact; there is no overt drainage.

OTHERS

HOME CARE ASSESSMENT

1. Family
Caregiver availability, skills, and responses: willingness and
ability to assume responsibility for care as needed (eg. Wound
care, catheter and tube management, meal preparation,
assistance with ADLS, shopping, transportation to and from
appointments), other available caregivers
Family role changes and coping: Effect on parenting and
spousal roles, sexuality, social roles, financial status
Financial resources: Ability to purchase necessary supplies
and equipment; other sources of funding or financial
assistance (eg. Medicare, Medicaid)
2. Community
Available community resources such as equipment and supply
companies, support and educational organizations and groups
(eg. Ostomy clubs, etc.) home health agencies or providers,
access to pharmacy services, transportation services for
medical care, etc.
3. Client
Self-care abilities: Ability to manage hygiene and other self-
care, to perform wound care as needed, to manage tubes and
stomas, and to manage prescribed mediations
Supplies required: wound care supplies such as dressings,
hypoallergenic tape, cleansing solutions, binders or slings,
elastic wraps, irrigating syringe and solution.
Assistive devices required: Walker, cane, raised toilet seat,
commode, overhead trapeze, grab bars
Current level of knowledge: Postoperative pain management,
wound care, dressing changes, urinary catheters or other
drains, activity restrictions, dietary prescriptions, prescribed
exercises (eg. Range-of-motion, post mastectomy exercises)
infection control measures such as hand washing

POTENTIAL POST OPERATIVE PROBLEMS

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 PROBLEM DESCRIPTION
RESPIRATORY
1. Pneumonia Inflammation of the alveoli
a. Infectious May be limited to one or more
pneumonia lobes (lobar) or occur as
scattered patches throughout
the lungs (bronchial); also can
involve interstitial tissues of
lungs
b. Hypostatic
Pneumonia
c. Aspiration Inflammatory process caused by
Pneumonia irritation of lung tissue by
aspirated material particularly
hydrochloric acid (HCL) from the
stomach
2. Atelectasis A condition in which the alveoli
collapse and are not ventilated
3. Pulmonary Blood clot that has moved to the
Embolism lungs and blocks a pulmonary
artery, thus obstructing blood
flow to a portion of the lung.
CIRCULATORY
1. Hypovolemia Inadequate circulating blood
volume
2. Hemorrhage Internal or external bleeding
3. Hypovolemic Internal tissue perfusion
shock resulting from markedly reduced
circulating blood volume
4. Thrombophlebitis Inflammation of the veins usually
of the legs and associated with a
blood clot
5. Thrombus Blood clot attached to wall of
vein or artery (most commonly
the leg veins)
6. Embolus Foreign body or clot that has
moved from its site of formation
to another area of the body (eg.
The lungs, heart, or brain
URINARY
1. Urinary Retention Inability to empty the bladder,
with excessive accumulation of
urine in the bladder
2. Urinary tract Inflammation of the bladder,
infection ureters or urethra
GASTROINTESTINAL
1. Nausea & Vomiting
CAUSE
Infection, toxins, or
irritants causing
inflammatory process
Common organisms
include: Streptococcus
pneumoniae, hemophilus
influenza, and
streptococcus aureus
Immobility and impaired
ventilation result in
atelectasis and promote
growth of pathogens
Aspiration of gastric
contents, food, or other
substances; often related
to loss of gag reflex
Mucuos plugs blocking
bronchial passageways,
inadequate lung epansion,
analgesics, immobility
Statis of venous blood
from immobility venous
injury from fractures or
during surgery, use of oral
contraceptives high in
estrogen, pre-existing
coagulation or circulatory
disorder
Fluid deficit hemorrhage
Disruption of sutures,
insecure ligation of blood
vessels
Severe hypovolemia from
fluid deficit or hemorrhage
Slowed venous blood flow
due to immobility or
prolonged sitting; trauma
to vein, resulting in
inflammation and
increased blood
coagulability
As for thrombophlebitis for
venous thrombi; disruption
or inflammation of arterial
wall for arterial thrombi
Venous or arterial
thrombus; broken
intravenous catheter, fat,
or amniotic fluid
Depressed bladder muscle
tone from narcotics and
anesthetics; handling of
tissues during surgery on
adjacent organs (rectum,
vagina, etc)
Immobilization and limited
fluid intake,
instrumentation of the
urinary tract
Pain, abdominal
distention, ingesting food
or fluids before return of
peristalsis, certain
medications anxiety
CLINICAL SIGNS
Elevated temperature,
cough, expectoration of
blood-tinged or purulent
sputum, dyspnea, chest
pain
Dyspnea, tachypnea,
tachycardia, diaphoresis,
anxiety; pleural pain,
decreased chest wall
movement; dull or absent
breath sounds; decreased
O2 saturation (SaO2)
Sudden chest pain,
shortness of breath,
cyanosis, shock
(tachycardia, low blood
pressure)
Tachycardia, decreased
urine output, decreased
blood pressure.
Overt bleeding (dressings
saturated with bright blood
in drains or chest tubes),
increased pain, increasing
abdominal girth, swelling
or bruising around incision
Rapid weak pulse,
dyspnea, tachypnea;
restlessness and anxiety;
urine output less than 30
ml. hr; decreased blood
pressure; cool clammy
skin, thirst, pallor
Slowed venous blood flow
due to immobility or
prolonged sitting; trauma
to vein, resulting in
inflammation and
increased blood
coagulability
Venous: same as
thrombophlebitis Arterial
pain: pain and pallor of
affected extremity;
decreased or absent
peripheral pulses
In venous system, usually
becomes a pulmonary
embolus; signs of arterial
emboli may depend on the
location
Fluid intake larger than
output; inability to void or
frequent voiding of small
amounts, bladder
distention, suprapublic
discomfort restlessness
Burning sensation when
voiding, urgency, cloudy
urine, lower abdominal
pain
Complaints of feeling sick
to the stomach, retching or
gagging
PREVENTION
Deep breathing exercises,
coughing, moving in bed,
early ambulation
Deep breathing exercises
and coughing, moving in
bed, early ambulation.
Turning, ambulation,
antiemboli stockings,
sequential compression
devices (SCDs)
Early detection of signs,
fluid and/ or blood
replacement
Early detection of signs
Maintain blood volume
through adequate fluid
replacement , prevent
hemorrhage; early
detection signs
Early ambulation, leg
exercises, antiemboli
stockings, SCDs,
adequate fluid intake
Venous: same as
thrombophlebitis
Arterial: maintaining
prescribed position; early
detection of signs
As for thrombophlebitis or
thrombus; careful
maintenance of IV
catheters
Monitoring of the intake
and output interventions to
facilitate voiding urinary
catheterization as needed
Adequate fluid intake,
early ambulation, Aseptic
straight catheterization
only as necessary, good
IV fluids until peristalsis
returns; then clear fluids,
full fluids, and regular diet;
antiemetic drugs if
ordered; analgesics for
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2. Constipation Infrequent or no stool passage
for abnormal length of time (eg.
Within 48 hours after solid diet
started)
pain
Lack of dietary roughage, Absence of stool Adequate fluid intake,
analgesics (decreased elimination, abdominal high-fiber diet, early
intestinal motility), mobility distention, and discomfort ambulation

3. Tympanites Retention of gases within Slowed motility of the
intestines intestines due to handling
of the bowel during
surgery and effects of
anesthesia
Obvious abdominal Eaqrly ambulation; avoid
distention, abdominal using a straw, provide ice
discomfort (gas pains), chips or water at room
absence of bowel sounds temperature

4. Postoperative ileus Intestinal obstruction
characterized by lack of
peristaltic activity
WOUND
1. Wound Infection Inflammation and infection of
incision or drain site
2. Wound dehiscence Separation of a suture line
before the incision
3. Wound Extrusion of internal organs and
evisceration tissues though the incision
Handling the bowel during
surgery, anesthesia,
electrolyte imbalance,
wound infection
Poor aseptic technique;
laboratory analysis of
wound swab identifies
causative microorganism
Malnutrition (emaciation,
obesity) poor circulation,
excessive strain on suture
line
Same as wound
dehiscence
Abdominal pain and
distention; constipation;
absent bowel sounds
vomiting
Purulent exudates
redness, tenderness,
elevated body
temperature, wound odor
Increased incision
drainage, tissues
underlying skin become
visible along parts of the
incision
Opening of incision and
visible protrusion of
organs
IV fluids until peristalsis
returns; gradual
reintroduction of oral
feeding; early ambulation
Keeping wound clean and
dry, surgicql aseptic
technique when changing
dressings
Adequate nutrition
appropriate incisional
support and avoidance of
strain
Same as for wound
dehiscence

PYSCHOLOGIC
1. Postoperative Mental disorder characterized by Weakness, surprise nature
Depression altered mood of emergency surgery,
news of malignancy,
severely altered body
image, or other personal
matter; may be a
physiologic response to
some surgeries
Anorexia, tearfulness, loss
of ambition, withdrawal,
rejection of others,
feelings of dejection, sleep
disturbances, (insomnia,
excessive sleeping)
Adequate rest, physical
activity, opportunity to
express anger and other
negative feelings

EVALUATION GOALS AND OUTCOMES: POSTOPERATIVE CLIENTS

GOALS
1. Maintain Comfort
2. Promote healing
3. Prevent risks associated
with surgery
4. Restore highest possible
EXAMPLES OF DESIRED OUTCOMES
Verbalizes satisfaction with pain control measures;
Absence of non-verbal indications of pain (eg. Protective body position, restlessness. Etc.)
Absence of physiologic indications of pain (eg.muscle tension, perspiration, change in BP, RR, HR)
Moves and ambulates with minimal difficulty
Rests for extended periods
Incision is clean, dry, and intact
Wound edges approximated well
Balanced fluid intake and output
Tolerating diet rich in fiber, protein, and vitamins A and C
Active bowels sounds within 48 hours
Normal defecation within 4 days
Hb, Hct, and serum electrolytes within normal limits
Performs deep breathing, coughing, and incentive spirometry as instructed
Normal auscultated breath sounds
Adequate respiratory excursion (depth)
Performs leg exercises as instructed
Walks increasing distances each day
Stable vital signs
Strong and equal peripheral pulses in all four extremities
Increasingly participate in self-care activities
Ask pertinent questions concerning ongoing care
Seeks help as appropriate
Demonstrates ability to care for incision
Reports ability to manage ongoing care

CONTROLLING POSTURAL HYPOTENSION
1. Sleep with the head of the bed elevated 8 to 12 inches. This
position makes the position change on rising less severe.
2. Avoid sudden changes in position. Arise from bed in three stages;
Sit up in bed for 1 minute
Sit on the side of the bed with legs dangling for 1 minute
Stand with care, holding onto edge of the bed or another non-
movable object for 1 minute. Gradual changes in position
stimulate rennin ( a kidney enzyme that has a role in regulating
blood pressure), which prevents a dramatic drop in pressure.
3. Never bend down all the way to the floor or stand up too quickly
after stooping. Baroreceptors (sensory nerve endings in the walls of
blood vessels) cannot accommodate rapid change.
4. Postpone activities such as shaving and hair grooming for at least 1
hour after rising. Baroreceptor reflexes are slow to respond after a
night of recumbency during sleep.
5. Wear elastic stockings at night to inhibit venous pooling in the legs.
6. Be aware that the symptoms of hypotension are most severe at the
following times:
30 to 60 minutes after a heavy meal
1 to 2 hours after taking an anti-hypertension medication
7. Get out of a hot bath very slowly, because high temperatures can
lead to venous pooling.
8. Use a rocking chair to improve circulation in the lower extremities.
Even mild leg conditioning can strenghten muscle tone and
enhance circulation.
9. Refrain from any strenuous activity that results in holding the breath
and bearing down. This Valsalva maneuver slows the heart rate,
leading to subsequent lowering of blood pressure.
HEALTH PROBLEMS THAT INCREASE SURGICAL RISK
Blood coagulation disorders may lead to severe bleeding,
hemorrhage, and subsequent shock.
Upper respiratory tract infections or chronic obstructive lung
diseases such as emphysema adversely affect pulmonary function,
especially when exacerbated by the effects of general anesthesia.
They also predispose the client to postoperative lung infections.
Renal disease or insufficiency impairs regulation of the bodys fluids
and electrolytes and excretion of drugs and other toxins.
Diabetes mellitus predisposes the client wound infection and
delayed healing.
Liver disease (eg. Cirrhosis) impairs the livers abilities to detoxify
medications used during surgery, produce the prothrombin
necessary for blood clotting, and metabolize nutrients essential for
healing
Uncontrolled neurologic disease such as epilepsy may result in
seizures during surgery or recovery.

4
 Malnutrition can lead to delayed would healing, infection, and
reduced energy. Protein and vitamins are needed for wound
healing; vitamin K is essential for blood clotting.
Obesity leads to hypertension, impaired cardiac function, and
impaired respiratory ventilation. Obese clients are also more likely
to have delayed wound healing and wound infection because
adipose tissue impedes blood circulation and its delivery of
nutrients, antibodies, and enzymes required for wound healing.
Cardiac conditions such angina pectoris, recent myocardial
infarction, hypertension, and congestive heart failure weaken the
heart. Well-controlled cardiac problems generally pose minimal
operative risk.
ASSESSING SURGICAL WOUNDS
TYPES OF WOUNDS
TYPE CAUSE
1. Incision Sharp instrument (eg. Knife or scalpel
2. Contusion Blow from blunt instrument
3. Abrasion Surface scrape, either intentional (eg. Scraped knee from a fall) or
intentional (eg. Dermal abrasion to remove pockmarks)
4. Puncture Penetration of the skin and often the underlying tissues by a sharp
instrument, either intentional or unintentional
R-Y-B COLOR CODE OF WOUNDS
1. Yellow Wounds
Characterized by liquid to semiliquid slough that is often
accompanied by purulent drainage
The nurse cleanses yellow wounds to remove nonviable
tissue.
Methods used for cleansing may include:
1. Applying wet to damp dressing
2. Irrigating the wound
3. Using absorbent dressing materials such as impregnated
nonadherent, hydrogel dressing or other exudates
absorbers.
4. Consulting the physician for the need of antimicrobials to
minimize bacterial growth.
2. Red Wounds
They are in the late regeneration phase of tissue repair
They need to be protected to avoid disturbance of
regenerating tissue
The nurse protects the wound by:
SKIN INTEGRITY AND WOUND CARE
SKIN INTEGRITY
The skin is the largest organ in the body
It mainly serves to protect the individual from injury
Intact skin refers to the presence of normal skin and skin layers
uninterrupted by wounds
A wound is a tear in the skin
TYPES OF WOUNDS
Intentional occurs during theraphy
Unintentional accidental
Closed no breakage in the skin
Open skin and mucous member surface is broken
WOUND DESCRIPTION:
Clean wounds uninfected wounds with minimal inflammation.
They are primarily closed wounds
Clean contaminated wounds are surgical wounds which the
respiratory, ailementary, genital or urinary tract has been entered.
Such wounds show no evidence of infection
Contaminated wounds include open fresh, accidental wounds and
surgical wounds involving a major break in sterle technique. They
show evidence of inflammation.
Dirty or infected wounds include old, accidental wounds
containing dead tissue and wounds with evidence of a clinical
infection (eg. purulent drainage)
PRESSURE ULCERS
Pressure ulcers are also called decubitus ulcers, pressure sores,
bedsores or distortion sores. It is caused by unrelieved pressure
that results to damage to underlying tissue.
Etiology: Pressure ulcers are due to localized ischemia, a deficiency
in the blood supply to the tissure. The tissue is caught between two
hard surfaces the surface of the bed and the bony skeleton. When
1. Appearance
Inspect color of wound and surrounding area and
approximation of wound edges
2. Size
Note size and location of dehiscence; if present
4. Drainage
Observe location, color, consistency, odor, and degree of
saturation of dressings. Note number of gauzes saturated or
diameter of drainage of gauze.
5. Swelling
Observe the amount of swelling; minimal to moderate swelling
is normal in early stages of wound healing.
6. Pain
Expect severe to moderate postoperative pain for 3 to 5 days;
persistent severe pain or sudden onset of severe pain may
indicate internal hemorrhaging or infection.
7. Drains
Inspect drain security and placement, amount and character of
drainage, functioning of collecting apparatus, if present.
DESCRIPTION
Open wound; painful; deep or swallow
Closed wound, skin appears ecchymotic (bruised)
because of damage
Open wound involving the skin; painful
Open wound
1. Gentle cleansing
2. Avoiding the use of dry gauze or wet-to-dry dressings
3. Applying a topical antimicrobial agent
4. Applying a transparent film or hydrocolloid dressing
5. Changing the dressing as infrequently as possible
3. Black Wounds
They are covered with thick necrotic tissue or eschar
Black wounds require debridement (removal of necromatic
material)
Removal of nonviable tissue from a wound must occur before
the wound can heal.
Debridement can be accomplished in four different ways:
1. Sharp scalpel or scissors are used
2. Mechanical scrubbing force or wet-to-damp dressings
3. Chemical used of collagenase enzyme agents
4. Autolytic dressings that contain wound moisture
facilitate the bodys own enzymatic breakdown of necrotic
tissue. This method takes no longer than the other three
but cause least damage to healthy surrounding tissue.
the blood cannot reach the tissues, the cells are deprived of oxygen
and nutrients, the waste products accumulate in the cells, and the
tissue consequently dies.
Reactive hyperemia bodys mechanism from preventing pressure
ulcers.
Two other factors that contribute in producing pressure ulcers
1. Friction force acting parallel to the skin surface
2. Shearing force combination of friction and pressure
RISK FACTORS THAT CONTRIBUTE TO THE FORMATION OF
PRESSURE ULCERS
Immobility
Inadequate nutrition
Fecal and urinary incontinence
Decreased mental status
Diminished sensation
Excessive body heat
Advanced age
STAGES OF PRESSURE ULCER FORMATION
STAGE 1: Nonblanchable erythema of intact skin
STAGE 2: Partial-thickness skin loss involving dermis, epedermis,
or both. The ulcer is superficial and presents clinically as an
abrasion, blister, or shallow crater.
STAGE 3: Full-thickness skin loss involving damage or necrosis of
subcutaneous tissue that may extend down to, but not through,
underlying fascia. The ulcer presents clinically as a deep crater with
or without undermining of adjacent tissue.
STAGE 4: Full-thickness skin loss with extensive destruction, tissue
necrosis or damage to muscle, bone, or supporting structures.
TYPES OF WOUND HEALING
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 Primary intention healing tissue surfaces have been approximated 5. Pain
(closed) and there is minimal or no tissue loss (eg. Surgical incision) 6. Body Image Disturbance
Secondary intention healing wound is extensive and involves 7. Anxiety
considerable tissue loss. Edges cannot be approximated (eg.
Pressure ulcers). Secondary intention healing differs from primary SKIN INTEGRITY AND WOUND CARE: PLANNING
intention healing in three ways: 1. Major goals for clients at risk for impaired skin integrity are:
1. The repair time is longer To maintain skin integrity.
2. The scarring is greater To avoid potential associated risks.
3. The susceptibility to infection is greater 2. Major goals for clients with impaired skin integrity are:
1. To promote wound healing
PHASES OF WOUND HEALING 2. To regain intact skin
1. Inflammatory Phase
2. Proliferate Phase HEALTH CARE SYSTEM
3. Maturation Phase It is the totality of services offered by all health disciplines.
In the past the primary purpose of the health care system was
KINDS OF WOUND DRAINAGE to provide care to the ill and injured but this has changed
Exudate is material, such as fluid and cells that has escaped from through the years.
blood vessels during the inflammatory process and is deposited in Health care services are commonly categorized according to
tissue or on tissue surfaces type and level.

Types of exudates:
Serous consists chiefly of serum (the clear portion of the blood)
Purulent thicker and with the presence of pus. Color may be blue,
green, or yellow- depending on causative organism.
Sanguineous consists of large amounts of RCBCs TYPES OF HEALTH CARE
1. Health Promotion and Illness Prevention
SKIN INTEGRITY AND WOUND CARE: ASSESSING The overall goal is to provide health care for all individuals by
1. Untreated wounds seen shortly after the injury. increasing access and distribution of health care services
Control severe bleeding by applying direct pressure over the Health promotion programs address areas such as adequate
wound and elevating the involved extremity. and proper nutrition, weight control and exercise, and stress
Prevent infection by cleaning abrasions and lacerations with reduction.
water and covering the wound with clean dressing or sterile 2. Diagnosis and Treatment
dressing. The largest segment of health care delivery system in the past
Control swelling and pain by applying ice over the wound and was devoted to diagnosis and treatment
surrounding tissue. Health educationtment
Control bleeding. Assess client for signs of shock. Environmental protection
2. Treated wounds are sutured wounds assessed to determine the Early detection and treatment
progress of healing.Inspected during dressing changes.
3. Assessment of treated wounds involves observation of the: Secondary Tertiary
Appearance Emergency Care
Long term care
Size Diagnosis and treatment
Care of the dying
Drainage (complex)
rehabilitation
Presence of swelling, pain Acute care
Status of drainage or tubes
4. Assessment of Pressure Ulcers SKIN INTEGRITY AND WOUND CARE: IMPLEMENTING
Location of the lesion 1. Supporting Wound Healing
Size of lesion in centimeters Nutrition and Fluids
Stage of the ulcer Preventing Infection
Color of the wound Positioning
Condition of the wound margins 2. Preventing Pressure Ulcers
Integrity of the surrounding skin Providing Nutrition
Clinical signs of infection Maintaining Skin Hygiene
Avoiding Skin Trauma
SKIN INTEGRITY AND WOUND CARE: DIAGNOSING Providing Supportive Devices
NANDA nursing diagnoses for skin wounds or who are at risk: 3. Treating Presure Ulcers
1. Risk for impaired skin integrity 4. The RYB Color Code (by Marion Laboratories)
2. Impaired Skin Integrity Red protect
3. Impaired Tissue Integrity Yellow cleanse
4. Risk for Infection Black - debridE